Minimally Invasive Surgery (MIS) has altered operative medicine in the past decades in many ways, through reduction of surgical trauma, pain and complications, as compared to open surgery. However, factors such as the requirement for highly trained surgeons and assistants, high cost of devices, aged non-ergonomic instrumentation, lack of precision in 2D videos during laparoscopic operations, loss of three-dimensionality and haptic sense, instrument and operational limitations, and others4, have hindered the use of laparoscopic surgery in wider applications. Recent advances in technology and medicine have the capacity to radically change the future of surgery as we currently know it. Our research vision is driven by the need to deliver ground-breaking healthcare technologies for safer, more intelligent and effective surgeries via the introduction and integration of next-generation innovations in artificial intelligence (AI), digital technologies, regenerative medicine, biofabrication, modelling, robot-assisted surgery, digital health, medical devices, and transplantation. The development of novel drug-loaded biomaterials and cell therapy procedures can further offer creative prophylactic approaches to surgery. The ultimate overarching goal is to transform the use of surgery by 2050, from just treating to also preventing recurring diseases. Thus, our high risk/high gain ambition is to revolutionise surgery through the development of innovative healthcare technologies that improve patient care and extend the quality of life for an increasingly ageing population, focusing also on disease prevention. Disease prevention is meant here in the context of early intervention, prophylactic operation, and prevention of illness recurrence or effective management of chronic conditions.

Muscles help us move, enable us to interact with objects and the environment, and regulate critical internal functions. Unfortunately, they are susceptible to damage due to disease, ageing and trauma and are a central factor in diverse serious healthcare conditions including sarcopenia (age-related loss of muscle mass and function, where decline in muscle mass between 40 and 80 years ranges from 30% to 50%), stroke, muscular dystrophy, multiple sclerosis, soft-tissue cancers, venous ulceration, diabetes, degenerative myopathy and incontinence (between 3 and 6 million people in the UK, and 24% of older people, suffer from urinary incontinence). The emPower Transformative Healthcare Technologies 2050 programme will overcome the limitations of current wearable assistive technologies and regenerative medicine by deploying engineered robotic artificial muscular assistance inside the body, exactly where it is needed, to: 1. restore strength and control in mobility and manipulation in older people who have lost muscle strength and precision; and 2. restore controllable muscular capabilities for sufferers of trauma, stroke, incontinence and degenerative diseases. This will have significant knock-on effects on whole-body and mind health through increased confidence, independence and quality of life, massively reducing the healthcare burden and facilitating the return of sufferers to productive and fulfilling lives. The emPOWER artificial muscles will be engineered to bridge the gap between the nanoscale of fundamental energy transduction phenomena and the centimetre scale of bulk muscle action, and will be implantable using minimally invasive (including robot-assisted) surgery and advanced imaging to replace or supplement ailing muscles, providing short-term rehabilitation, long-term assistance or complete functional restoration as needed. To achieve our vision, we have brought together leading experts in soft robotics, regenerative medicine, bio-interfacing, smart structures, synthetic biology, polymer chemistry, self-assembly, bio-printing and tissue analysis, and clinical partners in neuro-rehabilitation, cardiovascular disease, head and neck surgery, urology, geriatrics and musculoskeletal medicine. Together, and with key industrial and social care partners, we will deliver the foundational technologies and first-stage proof-of-concept of the emPOWER artificial muscles within the five years of this transformative project, leading to major healthcare, economic and social impact to 2050 and beyond.

'Autonomous systems' are machines with some form of decision-making ability, which allows them to act independently from a human controller. This kind of technology is already all around us, from traction control systems in cars, to the helpful assistant in mobile phones and computers (Siri, Alexa, Cortana). Some of these systems have more autonomy than others, meaning that some are very predictable and will only react in the way they are initially set up, whereas others have more freedom and can learn and react in ways that go beyond their initial setup. This can make them more useful, but also less predictable. Some autonomous systems have the potential to change what they do, and we call this 'evolving functionality'. This means that a system designed to do a certain task in a certain way, may 'evolve' over time to either do the same task a different way, or to do a different task. All without a human controller telling it what to do. These kinds of systems are being developed because they are potentially very useful, with a wide range of possible applications ranging from minimal down-time manufacturing through to emergency response and robotic surgery. The ability to evolve in functionality offers the potential for autonomous systems to move from conducting well defined tasks in predictable situations, to undertaking complex tasks in changing real-world environments. However, systems that can evolve in function lead to legitimate concerns about safety, responsibility and trust. We learn to trust technology because it is reliable, and when a technology is not reliable, we discard it because it cannot be trusted to function properly. But it may be difficult to learn to trust technology whose function is changing. We might also ask important questions about how functional evolutions are monitored, tested and regulated for safety in appropriate ways. For example, just because a robot with the ability to adapt to handle different shaped objects passes safety testing in a warehouse does not mean that it will necessarily be safe if it is used to do a similar task in a surgical setting. It is also unclear who, if anyone, bears the responsibility for the outcome of functional evolution - whether positive or negative. This research seeks to explore and address these issues, by asking how we can, or should, place trust in autonomous systems with evolving functionality. Our approach is to use three evolving technologies - swarm systems, soft robotics and unmanned air vehicles - which operate in fundamentally different ways, to allow our findings to be used across a wide range of different application areas. We will study these systems in real time to explore both how these systems are developed and how features can be built into the design process to increase trustworthiness, termed Design-for-Trustworthiness. This will support the development of autonomous systems with the ability to adapt, evolve and improve, but with the reassurance that these systems have been developed with methods that ensure they are safe, reliable, and trustworthy.